3-Part Video Series Trailer

https://www.youtube.com/watch?v=59mFhX02ffk&feature=youtu.

Leveraging Technology to Improve

Prior Authorization

Session #156 - February 13, 2019

Heather McComas, PharmD, Director, Administrative Simplification Initiatives, American Medical Association

Tyler Scheid, J.D., Senior Policy Analyst, Administrative Simplification Initiatives, American Medical Association

Heather McComas, PharmD – Director, Administrative

Simplification Initiatives, American Medical Association

Tyler Scheid, J.D. – Senior Policy Analyst, Administrative

Simplification Initiatives, American Medical Association

We have no real or apparent conflicts of interest to report.

Conflicts of Interest

• Setting the Stage

– Prior authorization (PA) physician survey data

• PA Reform Initiatives

– Prior Authorization and Utilization Management Reform Principles

– Consensus Statement on Improving the Prior Authorization Process

• Utilizing Technology to Improve PA

• Leveraging Social Media for PA Policy Reform

– AMA grassroots efforts

• Questions

Agenda

1. Recognize how PA negatively impacts patients and health care

professionals using available survey findings

2. Analyze the current status of electronic prior authorization (ePA)

adoption for prescription medications, identify current

impediments to adoption, and propose solutions to overcome

these barriers

3. Describe the challenges that must be addressed to achieve

widespread adoption of standardized, automated PA for medical

services

4. Explore use of technology to facilitate PA policy reforms

5. Outline how effective utilization of social media and grassroots

web technologies can drive important PA policy changes that will

benefit health care professionals, patients, and payers

Learning Objectives

Setting the Stage

PA physician survey data

• Utilization Management Programs: Cost-containment

protocols requiring physicians to receive advanced

approval before a health insurer will cover a particular

drug or medical procedure

– PA

– Step therapy

• Concerns:

– Delayed patient treatment

– Questioning practitioner’s medical judgment

– Manual, time-consuming process for both providers and payers that

requires resources that could otherwise be spent on clinical care

The Problem

• 1000 practicing physician respondents

• 40% PCPs/60% specialists

• Web-based survey

• 29 questions

• Fielded in December 2018

2018 AMA PA Survey Overview

Average PA Response Wait Time

Question: In the last week, how long on average did you and

your staff need to wait for a PA decision from health plans?

Source: 2018 AMA Prior Authorization Physician Survey

19%

20%

11%

12%

0% 20% 40% 60% 80% 100%

Don't know

More than 5 business days

3-5 business days

2 business days

1 business day

More than a few hours but less than 1 business day

A few hours

Under 1 hour

65% report

waiting at least

one business

day

26% report

waiting at least

three business

days

Care Delays Associated With PA

44%

36%

11%

20%

40%

60%

80%

100%

Always

Often

Sometimes

Rarely

Never

Don't Know

91% report

care delays

Question: For those patients whose treatment requires PA,

how often does this process delay access to necessary care?

Source: 2018 AMA Prior Authorization Physician Survey

Total does not equal 100% due to rounding.

Treatment Abandonment

Associated With PA

Question: How often do issues related to the PA process lead to patients abandoning

their recommended course of treatment?

20%

53%

21%

20%

40%

60%

80%

100%

Always

Often

Sometimes

Rarely

Never

Don't know

75% report that

PA can lead to

treatment

abandonment

Source: 2018 AMA Prior Authorization Physician Survey

Total does not equal 100% due to rounding.

Subtotal sums to 75% due to rounding.

Impact of PA on Clinical Outcomes

Question: For those patients whose treatment requires PA, what is your

perception of the overall impact of this process on patient clinical outcomes?

Source: 2018 AMA Prior Authorization Physician Survey

91%

Significant or somewhat NEGATIVE impact

No impact

Somewhat or significant POSITIVE impact

Physician Perspective on PA Burdens

Question: How would you describe the burden associated

with PA in your practice?

Source: 2018 AMA Prior Authorization Physician Survey

86%

12%

High or extremely high

Neither high nor low

Low or extremely low

Total does not equal 100% due to rounding.

Change in PA Burden Over the Last 5 Years

Question: How has the burden associated with PA changed over

the last five years in your practice?

10%

38%

50%

20%

40%

60%

80%

100%

Increased significantly

Increased somewhat

No change

Decreased somewhat

or significantly

88% report PA

burdens have

increased over the

last five years

Source: 2018 AMA Prior Authorization Physician Survey

• Volume

– 31 average total PAs per physician per week

• Time

– Average of 14.9 hours (approximately two business days) spent each

week by the physician/staff to complete this PA workload

• Practice resources

– 36% of physicians have staff who work exclusively on PA

Additional PA Practice Burden Findings

Source: 2018 AMA Prior Authorization Physician Survey

PA Reform Initiatives

Principles and Consensus Statement

• Released in January 2017 by coalition of AMA and 16 other

organizations

• Underlying assumption: utilization management will continue to be

used for the foreseeable future

• Sound, common-sense concepts

• 21 principles grouped in 5 broad categories:

– Clinical validity

– Continuity of care

– Transparency and fairness

– Timely access and administrative efficiency

– Alternatives and exemptions

Link to Principles: https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/principles-with-signatory-page-for-slsc.pdf

Prior Authorization and Utilization

Management Reform Principles

• American Medical Association

• American Academy of Child and

Adolescent Psychiatry

• American Academy of Dermatology

• American Academy of Family

Physicians

• American College of Cardiology

• American College of Rheumatology

• American Hospital Association

• American Pharmacists Association

• American Society of Clinical

Oncology

• Arthritis Foundation

• Colorado Medical Society

• Medical Group Management

Association

• Medical Society of the State of

New York

• Minnesota Medical Association

• North Carolina Medical Society

• Ohio State Medical Association

• Washington State Medical

Association

Over 100 additional organizations have signed on as supporters of the

Workgroup efforts following the January 2017 release of the Principles.

Prior Authorization Reform Workgroup

• Released in January 2018 by the AMA, American Hospital

Association, America’s Health Insurance Plans, American

Pharmacists Association, Blue Cross Blue Shield Association,

and Medical Group Management Association

• Five “buckets” addressed:

– Selective application of PA

– PA program review and volume adjustment

– Transparency and communication regarding PA

– Continuity of patient care

– Automation to improve transparency and efficiency

• GOAL: Promote safe, timely, and affordable access to

evidence-based care for patients; enhance efficiency; and

reduce administrative burdens

Link to Consensus Statement: https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf

Consensus Statement on Improving the

Prior Authorization Process

Utilizing Technology to

Improve PA

• Areas where solutions developed or well underway:

– Automation to improve transparency and efficiency

– Transparency and communication regarding PA

• Areas where less work has been done on solutions:

– Selective application of PA

– PA program review and volume adjustment

– Continuity of patient care

Using Technology to Address Areas of

the Consensus Statement

• Consensus:

– Encourage health care providers, health systems, health plans, and pharmacy

benefit managers to accelerate use of existing national standard

transactions for electronic prior authorization (i.e., National Council for

Prescription Drug Programs [NCPDP] ePA transactions and X12 278)

– Advocate for adoption of national standards for the electronic exchange

of clinical documents (i.e., electronic attachment standards) to reduce

administrative burdens associated with prior authorization

– Advocate that health care provider and health plan trading partners, such as

intermediaries, clearinghouses, and EHR and practice management system

vendors, develop and deploy software and processes that facilitate prior

authorization automation using standard electronic transactions

– Encourage the communication of up-to-date prior authorization and step

therapy requirements, coverage criteria and restrictions, drug tiers,

relative costs, and covered alternatives (1) to EHR, pharmacy system, and

other vendors to promote the accessibility of this information to health care

providers at the point-of-care via integration into ordering and dispensing

technology interfaces; and (2) via websites easily accessible to contracted

health care providers

Automation to Improve Transparency

and Efficiency

What it is:

• Automated exchange of patient clinical data between a provider

and a payer to facilitate utilization management determination

• Integrated within provider’s workflow in practice management

systems (PMS)/electronic health records (EHR) (vs. requiring use

of separate payer website portal)

• Uniform process across all payers

Why it’s needed:

• PA process today is manual (phone, fax) and time-consuming for

both providers and payers

• Current process leads to treatment delays and abandonment

• Automation saves all stakeholders time and resources, improves

communication, and most importantly, improves patient care

Standard Electronic Prior Authorization

• Improvement on manual processes, but NOT a universal solution

• Limitations/issues:

– Providers must exit usual EHR workflow to access portals

– Providers responsible for managing multiple log ins and

passwords

– Each portal is unique, and the lack of consistency burdens

providers

• Must learn individual nuances and adapt to each one

– Requires significant amount of data reentry from EHRs

• Any PA technological solution must have universal applicability in

order to satisfy provider needs and improve efficiency

The Problem with Portals

Solution to improve prescription PA process:

• NCPDP ePA

Solution to improve medical PA process:

• X12 278 for medical services PA

Electronic PA Standards

Standard History:

• ePA process involves four transactions established in the NCPDP SCRIPT

standard

• First published in NCPDP SCRIPT standard V2013071 (2013)

Legislative Mandates:

• H.R. 6 SUPPORT for Patients and Communities Act (Section 6062) -

10/24/18

– Standard, secure ePA system to be established no later than

January 1, 2021

– Facsimile, a proprietary payer portal that does not meet standards

specified by the Secretary, or an electronic form shall not be treated

as an electronic transmission

• States (including Minnesota, Delaware, and Ohio among others) have

passed legislation that requires payers to accept ePA requests for

prescription drugs

Prescription PA Process - ePA

• Payers:

– 96% of payers are committed to an ePA solution*

• Vendors:

– 79% of EHRs are committed to implementing ePA*

• Physicians:

– Provider adoption of technology is sluggish

– Only 51% of surveyed physicians were aware of ePA

technology

Status of Pharmacy ePA Adoption

# Source: 2017 AMA Prior Authorization Physician Survey

* 2018 CoverMyMeds ePA Scorecard

• Vendors not offering no-cost ePA solutions

• Lack of payer support of ePA technology

• Low physician awareness of ePA technology

• Data not being auto-extracted from EHRs

• Confusion/detraction of proprietary portals

• Lack of transparency of PA requirements in EHRs at point of

prescribing

Pharmacy ePA Adoption Challenges

• Urge vendors to build/offer ePA solutions at no cost to physicians

• Encourage all payers to support ePA technology

• Increase physician education

• Maximize technology to pull data from EHRs (vs reentry of data in

question sets)

• Improve accuracy of formulary data/improve real-time pharmacy

benefit transactions

Overcoming ePA Adoption Challenges

• Committed to educating providers about the advantages of ePA

• 3-part video series – Electronic Prior Authorization: A Better Way

AMA ePA Education Efforts

• X12 278 Health Care Services Review - Request for Review and

Response is HIPAA-mandated transaction for electronic PA

• CAQH CORE Phase IV Operating Rules address X12 278

connectivity issues (compliance is voluntary)

– CAQH CORE is developing additional Phase V Operating

Rules for X12 278 data content and web portals

Medical Services Electronic PA

• X12 278 implementation status

– X12 278 adoption reported at 12% (down from 18% in 2016

CAQH Index)*

• Barriers to adoption

– Lack of support across stakeholder groups

– Lack of an attachment standard to support clinical

documentation submission

– Investment in proprietary portals

– Multiple iterations of X12 278 to deliver final decision not

supported

Medical Services PA: X12 278 Adoption

Status and Challenges

*Source: 2018 CAQH Index Report

• Significant industry attention focused on finding solutions

– CAQH CORE Prior Authorization Subgroup/Rules Work Group

– WEDI Prior Authorization Subworkgroup

• Rule-making for electronic attachment standard

• Compliance enforcement for X12 278

• Supporting multiple iterations/conversational nature of PA

transactions

Overcoming X12 278 Adoption Challenges

• Consensus:

– Improve communication channels between health plans, health

care providers, and patients

– Encourage transparency and easy accessibility of prior

authorization requirements, criteria, rationale, and program changes

to contracted health care providers and patients/enrollees

– Encourage improvement in communication channels to support

(1) timely submission by health care providers of the complete

information necessary to make a prior authorization determination

as early in the process as possible; and (2) timely notification of PA

determinations by health plans to impacted health care providers

(both ordering/rendering physician and dispensing pharmacists) and

patients/enrollees

Transparency and Communication

Regarding PA

• Updated at predetermined times with data sets that are the same

for large groups of plan members

– Example: NCPDP batch Formulary & Benefit files

• Irregular/inconsistent updates result in outdated and inaccurate

information being presented to the prescriber

– Only 43% of surveyed physicians indicated that information

about PA requirements in their EHRs is often or always

accurate*

– In informal study using convenience sample of EHR

formulary data for 100,000 patients, only 33% of formularies

contained a least one drug with a PA flag (would expect

close to 100%)

• Inaccurate EHR formulary data can lead to prescription

abandonment and medication adherence issues

EHR Coverage Information: Static Data

*Source: 2017 AMA Prior Authorization Physician Survey

# Data on file, AMA

• Dependent on details such as patient utilization that do not apply

equally to a large group of plan members

– Examples:

• Real-Time Prescription Benefit (RTPB)

• HL7 Da Vinci Project

• Newer technologies relay patient-specific, real-time coverage

information at the point of care

EHR Coverage Information:

Transactional Data

What is RTPB?

• System that delivers patient-specific drug benefit and cost

information within the e-prescribing workflow

• Provides wide range of cost information including:

– Out-of-pocket costs, co-pays, and financial assistance

programs, among others

– Utilization management requirements (PA, step therapy)

– Preferred pharmacy information

• Provides visibility into patient-specific benefits at point of

prescribing

• Supports provider-patient conversations about drug selection

during office visits, thereby increasing chances of medication

adherence

Real-Time Prescription Benefit

RTPB Pilots

• Number of RTPB pilots from various vendors and PBMs have been introduced and

are gaining traction

• While promising, pilots have limitations including:

– No current solution provides coverage information for all payers

– Solutions use different syntaxes, hindering interoperability and

interconnectivity

RTPB Standard

• NCPDP RTPB Task Group is developing an RTPB standard that will have two

standard formats (Telecom and SCRIPT) and one implementation guide for the

real-time exchange of data between providers and payers. RTPB transaction will:

– Establish patient eligibility, product coverage, and benefit financials for a

chosen product and pharmacy

– Identify coverage restrictions, alternative products, and benefit alternatives

when they exist

Status of RTPB Adoption

Changes to Lower Drug Prices in Medicare Advantage and Part D

• 2018 proposed rule takes steps to increase transparency and

accelerate the use of RTPB solutions in Part D

– Proposes that each Part D plan adopt a RTPB tool of its

choosing by January 1, 2020

– Aggressive timeline may pose challenges for the industry

• No RTPB standard currently in place

RTPB and CMS Proposed Part D Rule

Background:

• A private-sector initiative that is leveraging HL7 Fast Healthcare Interoperability

Resources (FHIR) to improve data sharing in value-based care arrangements

– Solution is built around specific use cases

Goal:

• Develop a resource that functionally serves as the RTPB for medical benefits

Coverage Requirement Discovery Use Case:

• Providers need to easily discover which payer-covered services or devices have:

– Requirement for PA or other approvals

– Specific documentation requirements

– Rules for determining need for specific treatments/services

• With a FHIR-based API, providers can discover in real-time specific payer

requirements that may affect payer coverage of certain services or devices

HL7 Da Vinci Project

• Consensus:

– Encourage the use of programs that selectively implement prior

authorization requirements based on stratification of health care

providers’ performance and adherence to evidence-based medicine

– Encourage (1) the development of criteria to select and maintain

health care providers in these selective prior authorization

programs with the input of contracted health care providers and/or

provider organizations; and (2) making these criteria transparent

and easily accessible to contracted providers

– Encourage appropriate adjustments to prior authorization

requirements when health care providers participate in risk-based

payment contracts

Selective Application of PA

• Potential technological solutions:

– Payers can use data analytics to monitor provider performance to

see which providers have high PA approval rates to exempt them

from PA programs

• “Gold-carding” programs

– Payers will continue to use data analytics and monitoring

to make sure that gold-carded providers do not change

their prescribing/ordering habits

– Challenge: Gold-carding program information must be integrated

within EHRs so payer-specific exemptions are relayed to the

provider at the point of care/prescribing

Selective Application of PA

• Consensus:

– Encourage review of medical services and prescription drugs

requiring prior authorization on at least an annual basis, with

the input of contracted health care providers and/or provider

organizations

– Encourage revision of prior authorization requirements,

including the list of services subject to prior authorization, based on

data analytics and up-to-date clinical criteria

– Encourage the sharing of changes to the lists of medical

services and prescription drugs requiring prior authorization

via (1) provider-accessible websites; and (2) at least annual

communications to contracted health care providers

PA Program Review and Volume

Adjustment

• Potential technology solution:

– Payers can use data analytics to identify what drugs and

services have high approval rates and remove these from

the PA list

• Removing high-approval drugs and services from the PA

list eliminates unnecessary work for both payers and

providers, saving time and money

– Challenge: Payers must continually update coverage data

so that current, accurate PA requirements are available in

EHRs at the point of care

PA Program Review and Volume

Adjustment

• Consensus:

– Encourage sufficient protections for continuity of care during a

transition period for patients undergoing an active course of

treatment when there is a formulary or treatment coverage change

or change of health plan that may disrupt their current course of

treatment

– Support continuity of care for medical services and

prescription medications for patients on appropriate, chronic,

stable therapy through minimizing repetitive prior authorization

requirements

– Improve communication between health care providers, health

plans, and patients to facilitate continuity of care and minimize

disruptions in needed treatment

Continuity of Patient Care

• This area does not have fully developed solutions

– Improvements in payer system communication and

interoperability could facilitate information exchange

between payers

Potential technological solution:

• Blockchain/shared ledger technology

– After a patient switches plans, technology could allow payer

to see what treatments a patient previously utilized and

could avoid unnecessary repetition of utilization

management processes

• Potentially very useful for step therapy requirements

– Challenge: Security measures for sharing protected health

information through blockchain technology have not been

developed

Continuity of Patient Care

Leveraging Social Media for

PA Policy Reform

New grassroots website: FixPriorAuth.org

• Physician and patient tracks

• Social media campaign drives

site traffic and conversation

• Call to action: Share your story

• Most impactful stories

collected in site gallery

• Impressions: +8.0 million

• New users: +74,000

• Engagements: +340,000

• Patient/physician stories: +500

• Petitions signed: +89,000

(since mid-October)

FixPriorAuth.org: Grassroots Results Since

July 2018 Launch

Story

YOUR PRIOR

AUTHORIZATION

STORIES MATTER

FixPriorAuth.org

Story

Please share our videos and resources!

ama-assn.org/prior-auth

fixpriorauth.org

AMA Resources

Heather McComas, PharmD, Director, Administrative Simplification

Initiatives, AMA - heather.mccomas@ama-assn.org

Tyler Scheid, J.D., Senior Policy Analyst, Administrative

Simplification Initiatives, AMA – tyler.scheid@ama-assn.org

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